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Payment Receipt- SA Ambulance Services membership cover online application

SA Ambulance Cover Membership form

Please enter a valid authorised contact number Please select Health insurance provider. The residential address can not be validated, please correct or contact SA Ambulance on 1300 136 272 for assistance. The postal address can not be validated, please correct or contact SA Ambulance on 1300 136 272 for assistance.

Type of cover

Type of Cover *

Family ($198.00)

Single ($99.50)

Pensioner Concession Family ($118.00)

Pensioner Concession Single ($59.50)

ACE Family ($53.00)

ACE single ($26.00)

Ambulance Cover Plus

Please select the cover type first

Main applicant details

Title

Given Name

Family Name

Birth Date

dd/mm/yyyy format

Gender

M F X

Email address

Your receipt will be sent to you on the above provided email address

Contact No.

Other Contact No.

Residential Address

Enter manually if residential address not found

The residential address can not be validated, please correct or contact SA Ambulance on 1300 13 62 72 for assistance.

Unit/Apt/Room

Street Number

Street Name

Suburb/Town

Postcode

Extra Detail

Nursing home name etc.

My Postal Address is different to my Residential

Postal Address

Enter manually if postal address not found

The postal address can not be validated, please correct or contact SA Ambulance on 1300 136 272 for assistance.

GPO Box/Unit/etc

GPO Box/Unit No.

Street Number

Street Name

Suburb/Town

Postcode

Extra Detail

Nursing home name etc.

Dependants' details

Add Members

MembershipId	Given Name	Family Name	Gender	Birth Date	Fulltime student	Residing at home	PCC/DVA Number

Given Name

Family Name

Gender

Birth Date

Fulltime student

Residing at home

PCC/DVA Number

Insurance Details

Important Information

If you are a member of a Private Health Fund you should check your level of coverage before taking out ambulance cover subscription. In accordance with our terms and conditions Ambulance Cover is not refundable in part or in full and therefore you will NOT be entitled to a refund in the event you are otherwise insured. Also it is important to note that under our existing terms and conditions if you hold private health insurance you may receive a transport account and this is to be submitted to your insurer for payment in the first instance.

Health insurance provider

Pensioner Concession Card holder details

Are you eligible for a pension rate.

Pension No. CRN Format: xxxxxxxxxA

Note: The pension concession card rate does not apply to health care card or senior card holders. If you hold a DVA pension
please contact our Customer Service Centre on 1300 136 272 during office hours.

Authorised contact

Would you like to nominate a person who can do changes to your membership details on your behalf?

Title

Given Name

Family Name

Contact Number

Electronic Renewals

Complete the following details to receive renewals via SMS or email

Mobile Number

Email address

Opt out of Electronic Renewals (renewals will be posted)

Payment Details

* You may also like to make a donation to SA Ambulance Services.To do so, simply indicate the amount below in Donation amount you wish to pay.

Membership amount

Extra amount

Donation amount

Total amount

I have read, understood, and agree to the Terms and Conditions that apply to my selected level of ambulance cover, available at saambulance.sa.gov.au/membership/terms-and-conditions/

Note: Please check your membership details carefully before you proceed with payment.

Verification Code* :

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